Provider Demographics
NPI:1952624165
Name:SISWICK, HEATHER ANN (MA, LMHC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:SISWICK
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 4TH ST N STE 200
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2501
Mailing Address - Country:US
Mailing Address - Phone:727-513-2962
Mailing Address - Fax:727-499-7999
Practice Address - Street 1:9400 4TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2501
Practice Address - Country:US
Practice Address - Phone:727-513-2962
Practice Address - Fax:727-499-7999
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
FLMH23050101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300881Medicaid